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1.
Medicine (Baltimore) ; 99(6): e19031, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32028416

RESUMO

The study was designed to verify if mini-fluid challenge test is more reliable than dynamic fluid variables in predicting stroke volume (SV) and arterial pressure fluid responsiveness during spine surgery in prone position with low-tidal-volume ventilation.Fifty patients undergoing spine surgery in prone position were included. Fluid challenge with 500 mL of colloid over 15 minutes was given. Changes in SV and systolic blood pressure (SBP) after initial 100 mL were compared with SV, pulse pressure variation (PPV), SV variation (SVV), plethysmographic variability index (PVI), and dynamic arterial elastance (Eadyn) in predicting SV or arterial pressure fluid responsiveness (15% increase or greater).An increase in SV of 5% or more after 100 mL predicted SV fluid responsiveness with area under the receiver operating curve (AUROC) of 0.90 (95% confidence interval [CI], 0.82 to 0.99), which was significantly higher than that of PPV (0.71 [95% CI, 0.57 to 0.86]; P = .01), and SVV (0.72 [95% CI, 0.57 to 0.87]; P = .03). A more than 4% increase in SBP after 100 mL predicted arterial pressure fluid responsiveness with AUROC of 0.86 (95% CI, 0.71-1.00), which was significantly higher than that of Eadyn (0.52 [95% CI, 0.33 to 0.71]; P = .01).Changes in SV and SBP after 100 mL of colloid predicted SV and arterial pressure fluid responsiveness, respectively, during spine surgery in prone position with low-tidal-volume ventilation.


Assuntos
Pressão Sanguínea , Monitorização Intraoperatória/métodos , Posicionamento do Paciente , Medula Espinal/cirurgia , Volume Sistólico , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pletismografia/métodos , Decúbito Ventral , Estudos Prospectivos , Adulto Jovem
2.
World Neurosurg ; 133: e874-e892, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31541754

RESUMO

OBJECTIVE: The increasing challenges facing the training of future neurosurgeons have led to continued development of simulation-based training, particularly for neurosurgical subspecialties. The simulators must be scientifically validated to fully assess their benefit and determine their educational effects. In this second part, we aim to identify the available simulators for spine, pediatric neurosurgery, interventional neuroradiology, and nontechnical skills, assess their validity, and determine their effectiveness. METHODS: Both Medline and Embase were searched for English language articles that validate simulation models for neurosurgery. Each study was screened according to the Messick validity framework, and rated in each domain. The McGaghie model of translational outcomes was then used to determine a level of effectiveness for each simulator or training course. RESULTS: Overall, 114 articles for 108 simulation-based training models or courses were identified. These articles included 24 for spine simulators, 3 for nontechnical skills, 10 for 9 pediatric neurosurgery simulators, and 12 for 11 interventional neuroradiology simulators. Achieving the highest rating for each validity domain were 3 models for content validity; 16 for response processes; 1 for internal structure; 2 for relations to other variables; and only 1 for consequences. For translational outcomes, 2 training courses achieved a level of effectiveness of >2, showing skills transfer beyond the simulator environment. CONCLUSIONS: With increasing simulators, there is a need for more validity studies and attempts to investigate translational outcomes to the operating theater when using these simulators. Nontechnical skills training is notably lacking, despite demand within the field.


Assuntos
Competência Clínica , Procedimentos Neurocirúrgicos/educação , Treinamento por Simulação/métodos , Medula Espinal/cirurgia , Coluna Vertebral/cirurgia , Criança , Humanos , Radiologia/educação
3.
World Neurosurg ; 133: 142-149, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31557552

RESUMO

BACKGROUND: Split cord malformations (SCMs) are among the rare congenital spinal anomalies. In 1992, Pang et al. proposed the unified theory of embryogenesis and explained the formation of SCM type 1 and 2. This theory has been widely accepted in the neurosurgical literature, backed by several studies. However, there have been reports in the literature that defy both the classification as well as the formation of SCMs, based on the unified theory of embryogenesis. We report a case of SCM that does not fit into this classification scheme and try to elucidate its embryologic basis, with review of the relevant literature. We also attempt to include this variety into the existing classification system of SCMs. CASE DESCRIPTION: An 11-year-old boy presented with low backache after trivial trauma. He was neurologically intact. Imaging showed low-lying tethered cord and a midline ventral bony spur (D12, L1) with a single dural sac encasing both the hemicords. Surgical exploration showed a ventral bony spur with 2 hemicords, enclosed in a single dural tube. Excision of the bony spur and detethering of the filum terminal were performed. The postoperative course was uneventful and the patient was discharged satisfactorily. CONCLUSIONS: SCMs possibly represent a continuum of changes beginning at the gestational age of days 20-30. Terminology such as mixed or intermediate type is used to denote SCMs that show features of both type 1 and type II. We prefer using type 1.5 SCMs for all such cases, thereby avoiding confusion and maintaining uniformity in the nomenclature. However, further experimental studies are required to substantiate our understanding of these complex embryologic anomalies on the basis of current hypotheses.


Assuntos
Dor Lombar/cirurgia , Medula Espinal/anormalidades , Criança , Humanos , Dor Lombar/diagnóstico por imagem , Dor Lombar/patologia , Imagem por Ressonância Magnética , Masculino , Procedimentos Neurocirúrgicos , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Resultado do Tratamento
4.
J Neurosurg ; 131(6): 1690-1701, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31786544

RESUMO

Neuroendovascular surgery and interventional neuroradiology both describe the catheter-based (most often) endovascular diagnosis and treatment of vascular lesions affecting the brain and spinal cord. This article traces the evolution of these techniques and their current role as the dominant and frequently standard approach for many of these conditions. The article also discusses the important changes that have been brought to bear on open cerebrovascular neurosurgery by neuroendovascular surgery and their effects on resident and fellow training and describes new concepts for clinical care.


Assuntos
Transtornos Cerebrovasculares/cirurgia , Procedimentos Endovasculares/métodos , Procedimentos Neurocirúrgicos/métodos , Encéfalo/irrigação sanguínea , Encéfalo/cirurgia , Transtornos Cerebrovasculares/diagnóstico , Procedimentos Endovasculares/tendências , Humanos , Procedimentos Neurocirúrgicos/tendências , Medula Espinal/irrigação sanguínea , Medula Espinal/cirurgia
5.
Turk Neurosurg ; 29(6): 909-914, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31573062

RESUMO

AIM: To demonstrate the value of special intraoperative neuromonitoring techniques for cauda equina and conus medullaris tumors (CECMT) by describing standard methods used at our center. MATERIAL AND METHODS: Neurophysiological records were retrospectively reviewed for 16 patients (eight females and eight males; age range: 27â€"60 years) who underwent surgery for CECMT at our department between 2016 and 2018. RESULTS: Motor and/or sensorial deficits were preoperatively identified in 10 patients; no patients had bladder or sexual dysfunction. Motor evoked potential (MEP) loss occurred in seven patients with full or partial recovery. No changes were seen in pudendal somatosensory evoked potential (SEP) or bulbocavernosus reflex (BCR), and morphological deterioration and amplitude loss of tibial SEPs were present in four patients. Postoperatively, no new neurological deficits and/or bladder and sexual dysfunction were present. CONCLUSION: Pudendal SEP and BCR are useful tests for monitoring CECMT surgeries. BCR is an easily obtainable modality for preserving sacral functions and recommended as a primary monitoring modality in conjunction with traditional neurophysiological techniques during CECMT surgery.


Assuntos
Cauda Equina/fisiologia , Cauda Equina/cirurgia , Monitorização Neurofisiológica Intraoperatória/métodos , Neoplasias da Medula Espinal/cirurgia , Medula Espinal/fisiologia , Medula Espinal/cirurgia , Adulto , Cauda Equina/diagnóstico por imagem , Potencial Evocado Motor/fisiologia , Potenciais Somatossensoriais Evocados/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medula Espinal/diagnóstico por imagem , Neoplasias da Medula Espinal/diagnóstico por imagem
6.
J Clin Neurosci ; 70: 226-228, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31416734

RESUMO

The gold standard treatment of spinal dural arteriovenous fistulas (SDAVF) is surgical exclusion. The main surgical challenge is to localize the origin of the shunting vein and to ensure its complete exclusion. In that context, intra operative angiography technologies have been developed, such as fluorescein video angiography (FVA). The objective of this preliminary study was to assess the utility of FVA in SDAVF surgery through a short surgical series. We retrospectively studied the cases of six patients who had a FVA for a SDAVF. FVA was performed after dural opening and visualization of the suspected shunting vein. In 5 cases, FVA was performed after ligation to ensure the complete exclusion. In 2 cases, FVA was performed before the ligation to confirm the localization of the shunt. In 1 case, FVA was performed before and after ligation. FVA was judged useful in all cases to localize the origin of the shunting vein. FVA permitted to ensure the complete exclusion after ligation. No anaphylactic events were noticed. Our preliminary study suggests that fluorescein video angiography is feasible and helpful for SDAVF surgery.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Angiofluoresceinografia/métodos , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Estudos Retrospectivos , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Procedimentos Cirúrgicos Vasculares/métodos
7.
Stereotact Funct Neurosurg ; 97(2): 127-131, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31266040

RESUMO

Dorsal root entry zone (DREZ) lesioning is still used as a choice of treatment for some painful conditions as well as spasticity in selected patients. The most commonly used techniques to perform DREZotomy are the microsurgical one and DREZ radiofrequency (RF) coagulation. The technical difficulties using punctures to perform RF lesions include complications such as occurrence of lesions in the dorsal columns or in the corticospinal tract. This paper describes a new technical improvement in RF lesions at DREZ using intraoperative ultrasound (US) to optimize the lesions and to minimize the risk of complications. Using intraoperative US after laminotomy allows the surgeon to differentiate between the gray matter of the spinal cord and white matter, showing the correct entry zone, the angle to introduce the RF electrode, and the depth. Using intraoperative US to guide DREZ lesions provides real-time optimization of DREZotomy.


Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Laminectomia/métodos , Espasticidade Muscular/diagnóstico por imagem , Espasticidade Muscular/cirurgia , Raízes Nervosas Espinhais/diagnóstico por imagem , Raízes Nervosas Espinhais/cirurgia , Ultrassonografia de Intervenção/métodos , Adulto , Humanos , Masculino , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia
8.
J Clin Neurosci ; 68: 308-311, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31327592

RESUMO

BACKGROUND: Malignant Intramedullary Spinal Cord Tumor are a relatively uncommon entity affecting patients whose prognosis is quickly and relentlessly dismal. Since the '50s Spinal Cordectomy' has been advocated for the surgical management of these conditions, but to date, no standard operative protocol has been reported yet. OBJECTIVE: Although apparently "easy", burdened by virtually no further risk for the neurological function in paraplegic or severely paraparetic patients, SCt conceals notable pitfalls and surgical problems that are to date not yet completely discussed. The objective of the present paper is therefore to report a detailed stepwise description of the surgical technique. METHODS AND RESULTS: SCt addresses the problem of reaching a surgical radicality in patients whom neurological preoperative conditions have already irreversibly declined to a deep nonfunctional motor impairment and whose preoperative Brain MRI scan rules out intracranial seeding. The dural sac along with the radicular pouches must be considered as possible seeding and recurrence locations therefore such structure should be "en-bloc" removed. The cranial medullary end of the resection should be identified on the ground of the preoperative MRI and intraoperatively confirmed with fresh histological examinations ruling out the presence of tumor cells above the cordectomy. Due to the topographic and functional medullary arterial anatomy, no SCt should be performed above T3. The risk of postoperative sagittal imbalance is high and therefore a concurrent posterior vertebral stabilization is required. CONCLUSION: Spinal Cordectomy is a safe and feasible "last chance" treatment to prolong survival in paraplegic or severely paraparetic patients.


Assuntos
Glioma/cirurgia , Procedimentos Neurocirúrgicos/métodos , Paraplegia/complicações , Neoplasias da Medula Espinal/cirurgia , Adulto , Idoso , Feminino , Glioma/complicações , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Paraparesia/complicações , Medula Espinal/cirurgia , Neoplasias da Medula Espinal/complicações , Vértebras Torácicas , Resultado do Tratamento
9.
World Neurosurg ; 130: e953-e960, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31302279

RESUMO

BACKGROUND: Vascular malformations of the spinal cord are a rare and complex clinical entity and can lead to severe morbidity with progressive spinal cord symptoms if not treated properly. In early stages, the disease is characterized by slowly progressive, nonspecific symptoms, such as gait disturbance, paresthesia, diffuse sensory symptoms, and radicular pain; in the late stages, bowel and bladder incontinence, erectile dysfunction, and urinary retention may develop. In recent decades, understanding and treatment of spinal vascular malformations have improved with the evolution of diagnostic tools and treatment modalities; however, it is still difficult to manage these cases because of the complexity of the pathology. The aims of this study were to present the long-term outcomes of our patients and to discuss the optimal management strategies. METHODS: We reviewed the records of 78 patients with spinal vascular malformations and performed a retrospective, single-center case series evaluating initial occlusion, recanalization, retreatment, and neurologic status of patients with dural arteriovenous fistulas, perimedullary arteriovenous fistulas, arteriovenous malformations, and extradural arteriovenous fistulas who had undergone embolization and/or surgery. RESULTS: No mortality was observed. Complete obliteration was achieved in 76 patients (97.4%). CONCLUSIONS: Both endovascular and surgical treatment of spinal vascular malformations resulted in significant long-term recovery from myelopathic symptoms and improvement in quality of life for most patients.


Assuntos
Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Malformações Vasculares/diagnóstico por imagem , Malformações Vasculares/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medula Espinal/irrigação sanguínea , Resultado do Tratamento , Adulto Jovem
10.
World Neurosurg ; 130: 298-303, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31306838

RESUMO

BACKGROUND: A 61-year-old man was admitted complaining of myelopathy and back pain for 3 months. CASE DESCRIPTION: A 15-mm hemangioma with calcification was noted on magnetic resonance imaging and computed tomography. Intraoperatively, the mass was hard with ill-defined demarcation. The cranial portion of the mass was brown and dark gray on the dorsal cord. During surgery, motor evoked potentials transiently decreased, but they fully recovered at the end of surgery. After surgery, the patient's symptoms recovered without severe neurologic deficit. CONCLUSIONS: Hemangioma calcificans, a variant of cavernous hemangioma with full calcification and ossification, is an extremely rare disease in the spine and brain. Here we report a rare case of intramedullary cavernous hemangioma with calcification of the spinal cord.


Assuntos
Calcinose/patologia , Hemangioma Cavernoso/cirurgia , Neoplasias da Medula Espinal/cirurgia , Medula Espinal/cirurgia , Calcinose/diagnóstico , Potencial Evocado Motor/fisiologia , Hemangioma Cavernoso/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Medula Espinal/patologia , Neoplasias da Medula Espinal/diagnóstico , Coluna Vertebral/patologia , Tomografia Computadorizada por Raios X/métodos
11.
World Neurosurg ; 130: e1020-e1027, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31306848

RESUMO

BACKGROUND: Because spinal dural arteriovenous fistulae (SDAVF) are rare and their clinical presentation is nonspecific, they are often overlooked during diagnostic evaluations. Typical magnetic resonance imaging (MRI) findings are intramedullary T2-weighted signal hyperintensity and perimedullary flow voids. There are few reports on the characteristic signs of the cauda equina. We assessed the significance of a new imaging parameter, the cauda equina occupation ratio (CEOR), for the evaluation of SDAVF. METHODS: We retrospectively analyzed the clinical charts and radiological findings of 20 SDAVF patients treated at our institutions. We evaluated sagittal T2-weighted MRI scans and assessed the CEOR, the occupation ratio of the cauda equina compared to the sagittal diameter of the corresponding lumbar spinal canal. The controls were 21 age- and sex-matched subjects. RESULTS: Of the 20 SDAVF, 10 were at the thoracic and 10 at the lumbar spine. There was no significant difference between the preoperative CEOR and the spinal level of the fistulae or the neurological signs. On preoperative MRI scans, the mean CEOR was 56.0 ± 7.8; postoperatively, it was 37.1 ± 7.4 (P = 0.000). The preoperative CEOR was significantly larger in SDAVF patients than in the controls (P = 0.000); postoperatively, it was smaller than in the controls (P = 0.14). CONCLUSIONS: The preoperative CEOR was larger in patients with SDAVF than in the controls. It normalized after successful occlusion of the fistula. Our findings indicate that the CEOR is a useful parameter for the pre- and postoperative evaluation of SDAVF.


Assuntos
Cauda Equina/diagnóstico por imagem , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Vértebras Lombares/diagnóstico por imagem , Medula Espinal/diagnóstico por imagem , Vértebras Torácicas/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Cauda Equina/cirurgia , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Feminino , Humanos , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Medula Espinal/cirurgia , Vértebras Torácicas/cirurgia
12.
Handb Clin Neurol ; 160: 329-344, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31277858

RESUMO

Spinal cord surgery carries the risk of spinal cord or nerve root injury. Neurophysiologic monitoring decreases risk of injury by continuous assessment of spinal cord and nerve root function throughout surgery. Techniques include somatosensory evoked potentials (SEPs), transcranial electrical motor evoked potentials (MEPs), and electromyography (EMG). Baseline neurophysiologic data are obtained prior to incision. Real-time signal changes are identified in time to correct compromised neural function. Such monitoring improves postoperative neurologic functional outcomes. Challenges in neurophysiologic intraoperative monitoring (NIOM) include effects of anesthetics, neuromuscular blockade, hypotension, hypothermia, and preexisting neurological conditions, e.g., neuropathy or myelopathy. Technical factors causing poor quality data must be overcome in the electrically noisy operating room environment. Experienced monitoring teams understand tactics to obtain quality recordings and consider confounding variables before raising alarms when change occurs. Once an alert is raised, surgeons and anesthesiologists respond with a variety of actions, such as raising blood pressure or adjusting retractors. In experienced hands, NIOM significantly reduces postoperative neurological deficits, e.g., 60% reduction in risk of paraplegia and paraparesis. A technologist in the operating room sets up the NIOM procedure. An experienced clinical neurophysiologist supervises the case, either in the operating room or remotely on-line continuously in real time.


Assuntos
Potencial Evocado Motor/fisiologia , Potenciais Somatossensoriais Evocados/fisiologia , Monitorização Intraoperatória/métodos , Medula Espinal/fisiologia , Medula Espinal/cirurgia , Humanos , Monitorização Intraoperatória/normas , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/normas
13.
World Neurosurg ; 127: e585-e592, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30928589

RESUMO

BACKGROUND: Postoperative C5 palsy affects 8% of patients undergoing posterior cervical decompression. It is associated with a period functional disability that may exceed 12 months and increase direct care costs > $2000. METHODS: All patients undergoing posterior cervical decompression at a single tertiary-care facility for degenerative conditions were evaluated for preoperative imaging, clinical presentation, surgical operation, and postoperative course. We sought to identify those variables predictive of postoperative C5 palsy. RESULTS: Of 221 included patients (mean age, 63 years; 54% male), 12.2% experienced C5 palsy. On univariate analysis, C5 palsy was associated with foraminal diameter (P = 0.0005), spinal cord cross-sectional area (P = 0.11), number of levels undergoing laminectomy (P = 0.14), and clinical presentation of dropping objects (P = 0.07), hand clumsiness (P = 0.13), or paresthesias in the upper extremities (P = 0.08). Foraminal diameter (odds ratio, 0.31 per mm increase; 95% confidence interval, 0.16-0.60; P < 0.001) and patient report of gait disturbance (odds ratio, 0.53; 95% confidence interval, 0.33-0.85; P = 0.008) were the only significant predictors on multivariate analysis. A foraminal diameter <2 mm had 2-fold greater odds of postoperative C5 palsy. A receiver operating curve for the multivariate logistic model had an associated C-statistic of 0.7818. The absolute error of this model was 9.3% on internal validation. CONCLUSIONS: Foraminal stenosis most strongly predicted postoperative C5 palsy. A proof-of-concept model incorporating foramen size, as well as clinical complaints of paresthesias, hand clumsiness, and gait abnormality, successfully predicts the occurrence of postoperative palsy with an overall accuracy of 78%.


Assuntos
Vértebras Cervicais/cirurgia , Constrição Patológica/cirurgia , Paralisia/cirurgia , Complicações Pós-Operatórias/cirurgia , Adulto , Idoso , Descompressão Cirúrgica/métodos , Feminino , Humanos , Laminectomia/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Período Pós-Operatório , Fatores de Risco , Medula Espinal/cirurgia
14.
World Neurosurg ; 122: e655-e666, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30992117

RESUMO

BACKGROUND: Underestimation of the spinal cord's volume or position during spine stereotactic radiosurgery can lead to severe myelopathy, whereas overestimation can lead to tumor underdosage. Spinal cord delineation is commonly achieved by registering a magnetic resonance imaging (MRI) study with a computed tomography (CT) simulation scan or by performing myelography during CT simulation (myelosim). We compared treatment planning outcomes for these 2 techniques. METHODS: Twenty-three cases of spine stereotactic radiosurgery were analyzed that had both a myelosim and corresponding MRI study for registration. The spinal cord was contoured on both imaging data sets by 2 independent blinded physicians, and Dice similarity coefficients were calculated to compare their spatial overlap. Two treatment plans (16 Gy and 18 Gy) were created using the MRI and CT contours (92 plans total). Dosimetric parameters were extracted and compared by modality to assess tumor coverage and spinal cord dose. RESULTS: No differences were found in the partial spinal cord volumes contoured on MRI versus myelosim (4.71 ± 1.09 vs. 4.55 ± 1.03 cm3; P = 0.34) despite imperfect spatial agreement (mean Dice similarity coefficient, 0.68 ± 0.05). When the registered MRI contours were used for treatment planning, significantly worse tumor coverage and greater spinal cord doses were found compared with myelosim planning. For the 18-Gy plans, 10 of 23 MRI cases (43%) exceeded the spinal cord or cauda dose constraints when using myelosim as the reference standard. CONCLUSIONS: Significant spatial, rather than volumetric, differences were found between the MRI- and myelosim-defined spinal cord structures. Tumor coverage was compromised with MRI-based planning, and the high spinal cord doses were a concern. Future work is necessary to compare thin-cut, volumetric MRI registration or MRI simulation with myelosim.


Assuntos
Imagem por Ressonância Magnética/normas , Radiocirurgia/normas , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Tomografia Computadorizada por Raios X/normas , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/cirurgia , Feminino , Humanos , Vértebras Lombares/diagnóstico por imagem , Vértebras Lombares/cirurgia , Imagem por Ressonância Magnética/métodos , Masculino , Radiocirurgia/métodos , Neoplasias da Coluna Vertebral/diagnóstico por imagem , Neoplasias da Coluna Vertebral/cirurgia , Vértebras Torácicas/diagnóstico por imagem , Vértebras Torácicas/cirurgia , Tomografia Computadorizada por Raios X/métodos
15.
World Neurosurg ; 127: e1215-e1220, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31004857

RESUMO

BACKGROUND: Preoperative endovascular embolization of atypical hemangiomas of the spine can reduce intraoperative blood loss. One frequent concern raised about embolizing these tumors is a possible association with arteries feeding the spinal cord, such as the artery of Adamkiewicz. This study aimed to elucidate a relationship between spinal levels affected by atypical spinal hemangiomas and radiculomedullary arteries. METHODS: This was a retrospective review of 8 patients undergoing preoperative embolization of atypical spinal hemangiomas. We evaluated 54 spinal levels by angiography during embolization procedures. Each spinal level was categorized on the basis of the presence or absence of tumor and radiculomedullary artery. RESULTS: Six of 15 (40%) affected levels had an associated radiculomedullary artery. Four of 39 (10.2%) unaffected levels had an associated cord feeding artery. The relative risk of affected spinal levels having an associated radiculomedullary artery was 3.9 (95% confidence interval 1.28-11.91). The attributable risk was 0.40 (95% CI 0.12-0.76). The chi-squared statistic was 6.35, with a P value of 0.01. Six of 8 patients (75%) had a radiculomedullary artery at a level of disease and embolization. CONCLUSIONS: In this study, spinal levels affected by atypical hemangiomas requiring surgery were associated with radiculomedullary arteries. When performing preoperative embolization, great care must be taken to identify and preserve arteries supplying the spinal cord.


Assuntos
Hemangioma/diagnóstico por imagem , Hemangioma/cirurgia , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medula Espinal/irrigação sanguínea
16.
World Neurosurg ; 127: e416-e426, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30981802

RESUMO

BACKGROUND: Multimodal intraoperative neuromonitoring (IONM) has been proposed as an effective way to reduce permanent neurologic injury during spinal deformity surgery. However, few studies have reported evoked potential changes at different surgical stages of thoracic posterior vertebral column resection (PVCR). METHODS: A total of 82 cases with severe thoracic deformity (Yang's A type) treated by PVCR in a single institution between January 2010 and March 2015 were reviewed. Multimodal IONM including somatosensory evoked potential, motor evoked potential, and descending neurogenic evoked potential was performed for real-time assessment of spinal cord function during surgery. The risk factors of neuromonitoring events at different surgical stages were documented and analyzed. RESULTS: Multimodal IONM was successfully performed in all 82 cases. Thirty-nine neuromonitoring events presented in 27 (32.9%) cases. Neurologic monitoring events were more likely to occur in patients with larger scoliosis and kyphosis, longer osteotomy closure distance, more Halo gravity traction, more screw insertion, and higher PVCR segments. The reasons for monitoring changes included 6 events during screw insertion, 20 during osteotomy, 9 during osteotomy gap closure, and 4 during deformity correction. New postoperative neurologic deficits were observed in 11 (13.4%) cases including 1 incomplete paraplegia, 8 transient cord deficits, and 2 nerve root injuries. CONCLUSIONS: Multimodal IONM can effectively identify neurologic deficits throughout surgery. Osteotomy and osteotomy gap closure are the surgical stages with the highest neurologic risks during PVCR procedures. It is imperative to improve dexterity since the majority of neuromonitoring events are caused by surgical techniques.


Assuntos
Procedimentos Cirúrgicos Reconstrutivos , Escoliose/cirurgia , Medula Espinal/cirurgia , Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Criança , Potencial Evocado Motor/fisiologia , Potenciais Somatossensoriais Evocados/fisiologia , Feminino , Humanos , Cifose/cirurgia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Procedimentos Neurocirúrgicos/métodos , Osteotomia/métodos , Procedimentos Cirúrgicos Reconstrutivos/efeitos adversos , Adulto Jovem
17.
World Neurosurg ; 127: e943-e949, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30974280

RESUMO

OBJECTIVE: Spinal dural arteriovenous fistulas (SDAVFs) are rare vascular spinal malformations. According to the reported data, surgery seems to result in better occlusion rates than endovascular treatment. However, the post-treatment evolution of neurological symptoms stratified by the treatment remains unknown. The main objective of the present study was to compare the clinical outcomes for patients according to the treatment method. METHODS: The data from 63 patients with SDAVFs from 2000 to 2017 at 4 academic neurosurgical departments were retrospectively analyzed. Preoperative and postoperative examination neurological status was assessed using the Aminoff-Logue scale (ALS), which evaluates gait and micturition disturbances. Initial occlusion, late recurrence, and complications of the 2 techniques were also reviewed. RESULTS: Patients who had undergone surgery and embolization improved clinically on the ALS (P = 0.0009), and no significant differences were found between the 2 techniques. Subgroup analysis using the ALS showed that patients who had undergone surgery and embolization without late recurrence improved (P < 0.0001 and P = 0.0334, respectively) and that patients who had undergone surgery or embolization with late recurrence did not improve. The initial occlusion rate was in favor of surgery, with 91.3% versus 70% for endovascular treatment (P = 0.050). The late recurrence rate was higher for embolization (21.4% vs. 9.1% for surgery; P = 0.28). CONCLUSIONS: Surgery can be proposed as first-line treatment of SDAVFs after multidisciplinary discussion between neurosurgeons and neuroradiologists. The development of late recurrence negatively affects the neurological outcome of patients.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/cirurgia , Embolização Terapêutica , Procedimentos Neurocirúrgicos , Medula Espinal/cirurgia , Adulto , Idoso , Avaliação da Deficiência , Embolização Terapêutica/métodos , Procedimentos Endovasculares/métodos , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/métodos , Estudos Retrospectivos , Medula Espinal/irrigação sanguínea , Resultado do Tratamento
18.
J Neurol Surg A Cent Eur Neurosurg ; 80(4): 325-332, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30965372

RESUMO

Although multiple concurrent spinal arteriovenous fistulas (DAVFs) are a well-known anatomical and clinical entity, the management of these lesions and timing of surgical intervention is still a matter of debate.A 74-year-old man with a 2-year history of progressive weakness of both lower limbs and lower back pain was diagnosed angiographically with a thoracic DAVF. During the surgical procedure, double independent spinal DAVFs were identified. With the aid of neurophysiologic monitoring, we proceeded to the closure of both fistulas in a one-step surgery.Neurophysiologic monitoring represents a valid, widely available, minimally invasive tool for the detection of immediate motor fiber damage due to disruption of the incorrect vessels during DAVF surgery and facilitates a safe treatment in a one-step procedure.


Assuntos
Fístula Arteriovenosa/diagnóstico , Fístula Arteriovenosa/cirurgia , Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Medula Espinal/irrigação sanguínea , Idoso , Angiografia , Embolização Terapêutica , Humanos , Dor Lombar/diagnóstico , Dor Lombar/etiologia , Dor Lombar/cirurgia , Imagem por Ressonância Magnética , Masculino , Medula Espinal/cirurgia
19.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 30(2): 60-68, mar.-abr. 2019. ilus, graf, tab
Artigo em Espanhol | IBECS | ID: ibc-182003

RESUMO

Introducción: Hemos analizado la descompresión obtenida mediante corpectomía dorsal o dorsolumbar medida a través del ángulo de Cobb y el área del canal medular antes y después de la cirugía. Además, se ha comparado la evolución de la técnica entre los primeros 5 años del estudio y los 5 posteriores. Material y método: Se realizó un estudio retrospectivo de los pacientes operados entre 2005-2015 en nuestro centro mediante abordajes anteriores y posteriores. Resultados: Se intervinieron 24 pacientes y observamos una mejoría significativa entre los valores preoperatorios y postoperatorios en el análisis morfométrico (corrección de 4,18° de cifosis y un aumento del área del canal medular de 130,8mm2 con una significación de p<0,001 en ambos casos) y mejoría clínica (45,8% de los pacientes presentaron mejoría en la escala ASIA y una mejoría media de 13 puntos en el Karnofsky, p<0,001). Sin embargo, no se observa correlación entre los parámetros clínicos y morfométricos. También hemos observado que en los últimos 5 años del estudio los abordajes posteriores se utilizaron con mayor frecuencia y con buenos resultados. Conclusiones: La corpectomía dorsal permite una descompresión espinal significativa, con mejoría de la función neurológica sin que se correlacione con las mediciones de la descompresión. Gracias a las mejoras técnicas, las técnicas mínimamente invasivas (abordajes posteriores y técnicas MISS) permiten unos buenos resultados funcionales que son similares a los obtenidos con técnicas anteriores


Introduction: We analysed the decompression obtained by dorsal or dorsolumbar corpectomy measured by Cobb angle and the spinal area prior to and after surgery and compared the evolution of the technique over the last five years of the study. Material and method: A retrospective review of patients operated between 2005 and 2015 through anterior or posterior approaches was performed. Results: 24 patients were studied and a significant improvement was observed between the preoperative and postoperative morphometrical measurement (4.18° correction of the kyphosis and an increase of 130.8mm2 in the spinal canal, p<.001 in both cases) and in clinical parameters (45.8% of patients improved in ASIA, and Karnofsky showed 13 points of improvement, p<.001 in both cases). However, there was no correlation between clinical and morphological parameters. We also observed that in the last five years of the study posterior approaches were more frequently used with good results. Conclusions: Dorsal corpectomy allows significant spinal decompression, with neurological improvement but this does not correlate with the measurement of decompression. Thanks to technical improvements, less invasive techniques (posterior approaches and MISS) allow good clinical results, which are similar to those obtained by anterior techniques


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Adulto Jovem , Descompressão/métodos , Medula Espinal/diagnóstico por imagem , Medula Espinal/cirurgia , Compressão da Medula Espinal/diagnóstico por imagem , Estudos Retrospectivos , Coluna Vertebral/diagnóstico por imagem , Coluna Vertebral/cirurgia , Avaliação de Estado de Karnofsky , Compressão da Medula Espinal/cirurgia
20.
Exp Brain Res ; 237(6): 1551-1561, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30927042

RESUMO

Complexity in movement planning, arising from diverse temporal and spatial sources, places a computational burden on the central nervous system. However, the efficacy with which humans can perform natural, highly trained movements suggests that they have evolved effective behavioral strategies that simplify the computational burden. The specific aim of our research was to use three-dimensional high-speed video to determine whether the tail nociceptive withdrawal response (NWR) to noxious heat stimuli delivered at locations that varied both circumferentially and rostral-caudally on the tail depended on the location of the stimulus in spinalized rats. In particular, we sought to determine whether the movement strategy was categorical (limited number of directions) or continuous (any variation in stimulus location results in a variation in response direction). In spinalized rats, localized, noxious heat stimuli were delivered at eight locations circumferentially around the tail and at five rostral-caudal levels. Our results demonstrate that at all rostral-caudal levels, response movement direction was bimodal regardless of circumferential stimulus location-either ~ 64° left or right of ventral. However, in spite of tight clustering, movement direction varied significantly but weakly according to circumferential location, in that responses to stimuli were more lateral for lateral stimulus locations. In contrast, changes in stimulus level strongly affected movement direction, in that a localized bend response closely matched the level of the stimulus. Together, our results demonstrate, based on movement analysis in spinalized rats, that the NWR employs a hybrid categorical-continuous strategy that may minimize the harmful consequences of noxious stimuli.


Assuntos
Comportamento Animal/fisiologia , Movimento/fisiologia , Nociceptividade/fisiologia , Cauda/fisiologia , Animais , Masculino , Estimulação Física , Ratos , Ratos Sprague-Dawley , Medula Espinal/cirurgia , Temperatura Ambiente
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